use of interlocking intramedullary tibial nails in ... · pdf filereview article use of...

REVIEW ARTICLE

Use of Interlocking Intramedullary Tibial Nails inDeveloping Countries

Robert J. Feibel, MD,* and Lewis G. Zirkle Jr., MD†

Summary: Fractures of the tibia can be managed by Surgical ImplantGeneration Network intramedullary nail system in developing coun-tries. The entry point is an important aspect of achieving accuraterestoration of alignment. The fracture site should not be nailed in adistracted position. If distraction is observed, back-slapping the nailwill improve bone apposition. If fluoroscopy is not used for theprocedure, and the fracture site is noted to be distracted on post-operative x-rays, either revision surgery or early nail dynamizationshould be considered. Blocking (Poller) screws can be very helpful forproximal or distal tibial fracture management. Definitive wound closure ofopen fracture wounds should be achieved as soon as possible after theinitial debridement surgery usually by 3 to 7 days. Leave grossly contam-inated wounds open and covered with an antibiotic bead pouch if in doubtand perform repeat debridement 24 to 36 hours later. Segmental bone losscan be managed most commonly by autogenous iliac crest bone graftingalthough more sophisticated techniques such as bone transport are occa-sionally required.

Key Words: tibial fracture—intramedullary nail fixation—open frac-ture management—blocking screws—Surgical Implant GenerationNetwork (SIGN)—technique.

(Tech Orthop 2009;24: 233–246)

The Surgical Implant Generation Network (SIGN) solid,stainless steel nail was designed for use in the tibia and it is

strong enough for slots rather than holes to accommodate theinterlocking screw. Stainless steel was chosen because titaniumimplants may be more difficult to remove. The nail is straightbut the proximal and distal ends of the nail have a 9 and 1.5degree apex posterior bend, respectively. The nail is also usedfor femoral intramedullary (IM) nailing and these 2 bendscreate an effective radius of curvature which closely approxi-mates that of the normal human femur. There are 4 iterations ofthe interlocking screw which has broken in less than 0.5% ofSIGN interlocking nail surgeries.

Closed reduction is usually accomplished without imageintensifier use if the fracture is less than 7 to 10 days old. The openreduction technique for proximal tibial fractures is different fromthat of distal tibial fractures. We initially used many blockingscrews but these are used less frequently as the surgeon under-stands the technique of flexing the proximal fragment to at least110 degree during reaming and nail insertion.

What is not clear at this time is whether a solid, hollow-slotted, or cannulated nail has a lower infection rate1 nor is

there any conclusive evidence to suggest that titanium tibial IMnails are more biocompatible than stainless steel.2–5 The deepinfection rate for closed IM SIGN nailing was noted to be 1.9%(16/850 tibial nails) in a recent series.6

Preparation of the patient, positioning, entry point selec-tion, reduction of the fracture and locking screw fixation of awell-approximated, nondistracted fracture are important factorsaffecting the final clinical result.7,8 Patients with open fracturesrequire early soft-tissue coverage and a careful follow-up planto minimize the risk of infection and decrease the time tofracture union.

GENERAL CONSIDERATIONS

PreparationThe mechanism of injury and physical examination of the

injured limb are important factors because high energy frac-tures will be more likely to become unstable with cast immo-bilization and prone to delayed union and malalignment. Thedecision to proceed with surgery is made by both the patientand surgeon. The patient, and especially the injured leg, mustbe carefully inspected before surgery for degree of swelling,palpation of the muscle compartments, presence of openwounds or abrasions, neurovascular status, and overall clean-liness. Shaving of hair is not recommended.9

In the operating room, surgical instruments should bechecked before the patient enters the operating theater. Thesurgical site on the patient’s limb should be marked with an“X” and with the surgeon’s initials before entering the operat-ing room. On induction of an appropriate anesthetic, the sur-gical team must carry out a preoperative or preparatorypause10,11 to verify the surgical procedure to be performed andthe side of injury as recommended by the World HealthOrganization. The entire surgical team should be oriented to thenature of the procedure to be performed and the steps involved.

PositioningAfter induction of anesthesia, the patient should be posi-

tioned on the operating table such that at least 110 degrees ofknee flexion can be obtained (Fig. 1). Many surgeons use aflannel blanket placed under the ipsilateral buttock. This servesto place the transcondylar axis of the distal femur parallel to thefloor and assist with rotational alignment during IM nailing ofmultifragmentary tibial fractures. External rotation of the limbis also prevented by using such a roll. Triangles, bumps madefrom sterile gowns, dropping the end of the table, and placingthe leg over the side of the table may facilitate this degree ofknee flexion. The use of a padded kidney rest at the lateralaspect of the proximal thigh, often at the level of the tourniquetcan be used to maintain knee flexion and prevent externalrotation of the hip in deep knee flexion (Fig. 2). Care must betaken not to place any pressure on the neurovascular bundle inthe popliteal fossa.

From the *Division of Orthopaedic Surgery, University of Ottawa,Ottawa, Ontario, Canada; and †Surgical Implant Generation Network(SIGN), Richland, Washington, DC.

Address correspondence and reprint requests to Robert J. Feibel, MD,FRCSC, Suite 1652, Critical Care Wing, The Ottawa Hospital–GeneralCampus, 501 Smyth Rd, Ottawa, Ontario, Canada K1H 8L6. E-mail:[email protected] © 2009 by Lippincott Williams & WilkinsISSN: 0148-703/09/2404-0233

Techniques in Orthopaedics� • Volume 24, Number 4, 2009 www.techortho.com | 233

http://www.techortho.com

PRINCIPLES, METHODS, SURGICAL ACCESS

Closed ReductionClosed reduction should be attempted if the fracture is not

over 10 days old. The reduction technique varies based on thelevel of the fracture. Proximal fractures may be reduced byusing the Figure 4 position (Fig. 3) with emphasis placed onflexing the proximal fragment to 110 degrees. Flexing theproximal fragment in relation to the knee allows the tibial entrypoint to be placed in its appropriate position.

Determine the instability at the fracture site, taking intoconsideration the mechanism of injury and the x-ray appear-ance. Sometimes the unreduced fracture is stable in 1 directionbut not in another. Palpate the fracture site, visualize theposition and allow the operating surgeon to perform fracturereduction. More than 1 surgeon attempting to reduce the frac-ture does not work well. The surgeon must be allowed to focuson the reduction and not be rushed by the other surgeons whomay be offering advice. This is especially true for the juniorsurgeon who is trying to concentrate. Each surgical procedureshould be a learning process for all surgeons.

When using cannulated tibial nailing systems and imageintensification, a “cheat lateral” x-ray of the distal tibial can beobtained efficiently without swinging the C-arm into a full

lateral position. The “cheat lateral” simply requires the C-armto be rotated 20 to 30 degrees away from the surgeon andfractured tibia. The operating table is rotated toward the sur-geon 10 to 15 degrees, the leg is externally rotated 20 to 30

FIGURE 1. Patient positioning.

FIGURE 2. Care must be taken not to place any pressure on theneurovascular bundle in the popliteal fossa. The surgeon maysupport the leg by holding the distal portion of the posteriorthigh.

FIGURE 3. Figure 4 position for proximal tibial fractures. Thisposition results in a varus force across the fracture site and decreasesthe potential for fixation of the fracture in valgus alignment.

FIGURE 4. “Cheat” lateral x-ray. When using an image intensifier,positioning of the guide wire for a cannulated intramedullary nailsystem is noted in the distal tibia by gentle external rotation of theleg and rotation of the OR table toward the surgeon.

Feibel and Zirkle Jr. Techniques in Orthopaedics� • Volume 24, Number 4, 2009

234 | www.techortho.com © 2009 Lippincott Williams & Wilkins


degrees and a few degrees of gentle external rotation at thefracture site allow the centering of the guide wire to bevisualized on the lateral ankle view (Fig. 4). This maneuveravoids possible contamination of the set-up as the C-armswings to a lateral position.

Significance: Each operating room has opportunitiesand limitations when performing closed reduction.

Incision and Proximal Tibial Entry PointThere are different recommendations regarding where

the bone entrance point should be placed. In general, themore proximal the fracture, the more lateral the entry pointshould be. Some believe that the entry point should bemedial to the lateral tibia spine.12 Anatomic dissectionsreveal the lateral meniscus to be at risk with a lateralparapatellar approach and care is required to avoid injury.13

Tornetta states that “the safe zone is located 9.1 millimeterslateral to the center of the plateau and 3 millimeters lateralto the center of the tibial tubercle.”14 The surgeon cannot usethese landmarks without imaging. The patella tendon ispalpated with the knee in flexion. A central longitudinalincision through the tendon allows a predictable and accu-rate placement of the bone entrance when an image intensi-fier is not used (Fig. 5). The fat pad should never beentered.15,16 The bony entrance is anterior to the articularsurface (Fig. 6). A curved awl is used and is directedanteriorly, especially in a proximal tibia fracture (Fig. 7).Usually several passes of the awl provide a good pathwayfor the reamers.

A common error in proximal tibial fractures is to placethe entry point too anteriorly. This results in the nail pathcoursing from proximal anterior to distal posterior in theproximal fragment resulting in a procurvatum deformity(Fig. 8). This frequently requires blocking screw placementto correct the malalignment. An anterior entry point alsoputs the patient at risk for anterior cortical bone loss asprogressively larger diameter reamers remove anterior bone.This is especially true for pneumatic reaming and can beminimized by pushing the reamer head though the entrypoint and pulling the reamer head out without power. This isnot a concern using the hand reamers (Fig. 9). Anothercommon error is to use a medial parapatellar entry point forproximal tibial fractures which tends to result in nailing ofthe fracture in a valgus position. A transpatellar tendonapproach is preferred and carries no increased risk of ante-rior knee pain.17,18 The reduction may also be achieved bymeans of knee flexion and placement of the limb in the“Figure 4” position (Fig. 10).

FIGURE 5. A central incision through the tendon (A) allows theproper placement of the bone entrance, especially when imageintensification is not available. A medial parapatellar incision iscommonly used (B). A lateral parapatellar incision (C) is usedinfrequently due to the potential for lateral meniscus injury.

FIGURE 6. Tibial entry point. The fat pad should never beentered. The bony entrance is anterior to the articular surface.

FIGURE 7. Awl insertion. Do not allow the awl or reamers to“walk” down the anterior aspect of the tibia. This will result inreaming out the anterior cortex.

Techniques in Orthopaedics� • Volume 24, Number 4, 2009 Interlocking Tibial IM Nailing

© 2009 Lippincott Williams & Wilkins www.techortho.com | 235


Significance: Incising the patella tendon longitudinallyleads the surgeon to the proper bony entrance.

ReamingSeveral studies have demonstrated a benefit to IM ream-

ing19–22 in terms of improved union rates. The 7 to 9 mm SIGNhand reamers are pointed and should be rotated clockwise by thesurgeon as the reamer head is advanced along the medullary canalof the distal fragment. The 10 to 15 mm reamers are blunt-tippedto prevent cortical perforation in osteoporotic bone. An additionalbenefit of these blunt reamers is that the length of the planned nailcan be determined by passing the reamer tip until it reaches thephyseal scar or subchondral bone at the ankle (Fig. 11). Markingson the large SIGN reamers may be used to determine the appro-priate nail length.

After reduction, reaming is accomplished by starting with the7 mm reamer and progressively increasing the diameter untilchatter is felt for at least a 4 cm distance along the canal. Theresistance to progression of the reamer is also an indicator. Oneshould feel the reamer in its full 180 degrees arc to know the

reamer is in the canal. If there is a question about whether thereamer is in the canal, push on it and see whether there is a stop.If not, the reamer is not in the canal. The length of the nail ismeasured by pushing the blunt reamer until it abuts the subchon-dral bone of the ankle joint. An x-ray of the opposite unfracturedtibia may be used as a guide but is not as accurate as clinicalestimates or reamer depth. The surgical team may check nailinventory preoperatively by estimating nail length using anthro-pometric measurements: tibial tuberosity to medial malleolus;joint line to medial malleolus; olecranon to head of fifth metacar-pal head distance or normal tibia from knee joint line to ankle jointline less 20 mm. The knee joint line to ankle joint line less 20 mmmeasurement is the most reliable and has shown the best correla-tion (0.982) with ideal nail lengths.23

The bone from the flutes of the hand reamer should beretained if the fracture site has been opened. Store the bone inblood without contact with a sponge, normal saline or sterilewater. Passing the reamers through the fracture site has beendescribed in the reduction section. Care should be taken toavoid cortical heat necrosis by deflating the tourniquet during

FIGURE 8. A, Anteroposterior and lateral (B) views of a multifragmentary proximal tibial fracture in a 43-year-old woman. C, Lateralview showing the proposed skin incision marked under x-ray fluoroscopy with the tip of a knife blade centered within the handle of ahemostat. D, Drill insertion with the initial Kirschner wire defining the entry path of the nail. Note that the entry point is slightly distalthan is ideal. This type of distal entry point will increase the need for proximal blocking screws. Screw insertion is noted on the lateralview (E) and on the anteroposterior view (F). As the intramedullary nail is inserted, the procurvatum deformity is seen on the lateral view(G) and alignment corrects on full IM nail seating (H). Photos courtesy of Dr. Mark Steeves and Dr. Steven Papp.




power reaming and a limited-ream approach is recommendedfor high-energy fractures.24 Heat necrosis and damage to thepulmonary system is negligible when hand reaming is used.

Significance: The advantage of hand reaming is thatthe surgeon can feel when the reamer is in the bone,measure the length and diameter of the nail from the

reamers and use the bone from the flutes of the reamersfor a bone graft.

The nail is then attached to the target arm, and the target armis adjusted. The target arm is then removed and the locking boltand L-handle are used to introduce the nail (Fig. 12). Reductionmust be maintained during this process. The nail is placed eitherby direct pressure from the surgeon or by light taps using themallet. The nail has a 1.5 degrees bend in the distal end andtherefore the nail is twisted after each 3 taps. The surgeon soonbecomes familiar with this feel when the nail is in the canal. Donot force the nail. Ream larger or use a smaller nail if the nail doesnot progress easily. The ring on the stem tube of the L-handlehelps the surgeon decide the depth of the nail.

Significance: The surgeon’s tactile sense guides place-ment of the nail through the fracture site.

Distal Interlocking

Reattach the Target ArmThe target arm is reattached and the alignment pin used to

dimple the skin. Interlocking screws are placed through themedial side of the tibia. If 2 screws are used, dimple the skin bypassing the alignment pin through both apertures and connectthe dots. Avoid injury to the saphenous vein and nerve (Fig.13). Distal interlock should be done before proximal interlockto allow the nail to be rotated to adjust orientation of the slot forscrew insertion. Reattach the target arm to the L-handle. Besure the locking bolt connecting the L-handle to the nail istightly secured.

Insert CannulaUse the alignment pin to mark the location of the skin

incision. Dissect the bone with a periosteal elevator to remove allsoft tissues. Place the cannula through the incision down to the

FIGURE 9. Reaming. Always make sure that the fracture isreduced prior to passing the reamers.

FIGURE 10. A, “Figure 4” position. The knee is flexed and thehip externally rotated. B, This results in a varus force across thefracture site which will resist the tendency of a proximal tibialfracture to be nailed in valgus alignment.

FIGURE 11. The length of the planned nail can be determinedby passing the hand reamer tip until it reaches the physeal scar orsubchondral bone at the ankle.




bone using a clamp to spread and remove the soft tissues fromunder the cannula. Tight bands of tissue must not displace thecannula.

Significance: The cannula must rest directly on thebone.

Drilling the Near CortexInsert the small drill guide into the cannula. Drill a hole in the

near cortex (Fig. 14) using the small drill bit. If the bone is hard,do not maintain persistent pressure on the drill. Pulsing the drillinvolves drilling for 10 seconds followed by withdrawal of thedrill to allow it to cool. The drill bits become dull when heated.Change the small drill guide to the large drill guide and use thestep drill to enlarge this hole. The large drill bit may also be usedwhen the bone is too hard for the step drill. Stop immediatelywhen the step drill engages the slot in the nail. The hole can nowaccommodate the slot finders and the threaded head of the screws.

Significance: Pulse the drill in hard bone and stoprotation when the step drill is in the slot of the nail.

Insert Solid Slot FinderThe solid slot finder is used to find the slot in the nail

(Fig. 15). Insert the solid slot finder into the cannula. Thesolid slot finder is stronger and has a narrower tip than thecannulated slot finder. The solid slot finder is aligned usingthe flat portion of the handle with the plane of the nail. It isthen pushed into the slot in the nail. It is not placed byrotation. The “SIGN feel” can be demonstrated when the slotis in the nail (i.e., 10 degrees rotation either way). If the slotfinder does not rotate at all it is only partially inserted into

the slot in the nail so rotate the nail using the L-handle. If theslot finder rotates 360 degrees, it is not in the slot, rotate thenail to help find the slot finder in the slot.

If the solid slot finder does not enter the slot in the nail,there may be bone either in the near cortex hole or in the slotin the nail, or the hole may be maldirected. Use the screw holebroach to clear the hole. If the slot finder rotates more than 20degrees, it is not in the slot of the nail. If the slot finder does notrotate at all, it has been placed obliquely through the slot of thenail. Rotate the nail, so the slot finder will be inserted properlyinto the slot of the nail.

After the slot finder enters the slot in the nail replace itwith the cannulated slot finder. Once the cannulated slot finderhas been placed through the slot of the nail, the drill bit isplaced through it and the hole drilled in the far cortex (Fig. 16).SIGN drill bits are not disposable, hence it is important that thetips do not hit metal. When a notch or defect is placed in a drillbit tip, the drill heats up and becomes dull very quickly.

Distal Interlocking TipsReasons why the slot finder may not enter the slot in the nail:

1. The hole in the near cortex has been incompletely drilledand therefore the screw hole broach is needed to remove therim of bone at the bottom of the hole.

2. The reduction has been lost and the bone has shifted after the nailwas inserted.

3. The most common cause of failure to locate the slot isrotation of the nail on the insertion handle due to looseningof the locking bolt within the threads of the proximal end ofthe nail. Be sure that the locking bolt is tightened beforeattempting interlock. Use the same principle as when using

FIGURE 12. The locking bolt (A) is used to attach the target arm (B) and the target arm length is adjusted to match the nail. The targetarm is then removed and the locking bolt and L-handle are used to introduce the nail (C). Reduction must be maintained during theprocess.




a C-arm. The surgeon lines up the 2 apertures so they areparallel. Once the surgeon understands the value of rotation,distal interlocking without a C-arm is very quick and reli-able. Sometimes this rotation must be accounted for byusing the curved slot finder. The target arm is removed anda curved slot finder placed into the slot. If it is placed onlypartially in the slot, rotate the nail for complete placement inthe slot. The curved slot finder is then replaced by thecannulated slot finder.

4. The nail has been bent by a tight tibial canal. This will occurif heavy blows are used to strike the nail. Two or 3 light tapsand then a 20 degree twist of the nail is the proper technique.

Significance: The target arm guides longitudinal place-ment of the screw hole in the transverse direction. Rotationof the nail facilitates placement of the slot finders in thedistal slot in the nail. This technique is reliable and efficient.

Measure for Screw Length and Insert ScrewThe depth gauge is placed through the cannulated slot

finder and left in place as the slot finder and drill guide areremoved (Fig. 17). The depth gauge is calibrated to be read offthe side of the cannula. We add 2 or 3 mm so the proximal endof the screw can be left slightly prominent in case removal isrequired at a late date. Keep the cannula over the hole in the

near cortex and then push the screw through the hole in the nearcortex and slot in the nail. The surgeon will feel the screwthreads pass through the slot and engage in the far cortex.Determine whether the distal interlocking screw is through theslot in the nail by rotating the L-handle. If the screw is in theslot, the nail can be rotated 10 degrees. Pull the cannula back tovisualize the head of the locking screw to be sure it is notinserted too far into the near cortex. This is a risk when lockingscrews are inserted in osteoporotic bone.

The alignment pin is placed through the hex hole in thehead of the screw to align the target arm for placement of asecond distal interlocking screw (Fig. 18). The surgeon mustdecide whether 1 or 2 screws is necessary. This depends on thestability of the fracture, distance from the slot to the fracturesite, and location of the fracture.

Compression of the FractureOnce the distal interlocking screw or screws have been

placed, the fracture may be compressed, if necessary. This isaccomplished by attaching the extractor-compressor rod con-taining the weight and backslapping the fracture (Fig. 19). Thisis particularly important in the treatment of tibial nonunion.Make sure that the IM nail has been countersunk into bone ofthe proximal tibia when backslapping is being considered. This

FIGURE 13. Reattach the target arm (A)and use the alignment pin to dimple theskin. Interlocking screws are placed throughthe guide on the medial side of the tibia (B).Avoid injury to the saphenous vein andnerve.




will prevent prominence of the proximal nail and difficultieswith kneeling. Similarly, if the tibial fracture remains over-lapped and shortened, it can be lengthened at the fracture siteby performing distal interlocking, further impaction of the nailfollowed by proximal interlocking.

Significance: The extractor-compressor is used afterdistal interlocking to compress or lengthen the fracture site.

The number of screws decreases as the surgeon becomesmore confident in the SIGN system. Clinical results haveshown that 1 distal locking screw has been sufficient on manyoccasions.25,26 The fact that there are threads in the near and far

cortex for fixation of the screws may provide more stability.Clinical results from the SIGN database have yielded a verylow incidence of broken locking screws. If 1 distal lockingscrew is used, it should be placed in the proximal slot.

Placement of the Proximal Interlocking ScrewThe target arm is replaced if it has been removed and

should be firmly attached to the L-handle. Insert the alignmentpin tip to the skin surface to mark the location of the skinincision. Incise the skin and clear soft tissue off the bone. Insertthe cannula onto the bone of the medial tibial surface. Use thecannula, small drill guide and small drill bit to drill a holethrough the near and far cortices. Note that the slot finder is not

FIGURE 14. Insert the small drill guide into the cannula. Use thesmall drill bit to drill a hole in the cortex. Change the small drillguide to the large drill guide to enlarge the hole in the nearcortex.

FIGURE 15. Insert the solid slot finder into the cannula. Thesolid slot finder is aligned using the flat portion of the handle withthe plane of the nail.

FIGURE 16. After the slot finder enters the slot in the nail,replace it with the cannulated slot finder and drill a hole in the farcortex (A). If the slot finder will not enter the slot in the nail,consider enlarging the hole in the near cortex to remove a rim ofbone (B).




necessary to find the nail slot for proximal interlock. The holesare enlarged using the step drill and the interlocking screwplaced using the usual measurement and insertion process (Fig.20). The placement of 2 screws in the proximal tibia isrecommended. This is not always followed by all SIGN sur-geons and is an area in need of future study.

Significance: The slot finders are not used to find theslot and hole in the proximal nail.

Wound ClosureThe incision through the patellar tendon is closed first.

Only the tendon sheath needs be closed. The wound over thefracture is closed. Placing drains has been a common practicein developing countries but is not recommended.27,28 A 2007Cochrane database review noted: “Pooling of (multiple study)

results indicated no statistically significant difference in theincidence of wound infection, hematoma, dehiscence or reop-erations between those allocated to drains and the undrainedwounds. Blood transfusion was required more frequently inthose who received drains. The need for reinforcement ofwound dressings and the occurrence of bruising were morecommon in the group without drains. There is insufficientevidence from randomized trials to support the routine use ofclosed suction drainage in orthopaedic surgery.”29

AftercareIn stable fractures, early weight-bearing as tolerated is

recommended. Weight-bearing is determined by the stability ofthe fracture. The time to full weight-bearing is significantlydelayed in high-energy and open fractures.21

FIGURE 17. The depth gauge is placed through the cannulated slot finder. Remove the cannulated slot finder and read the depthgauge (A). B, Keep the cannula over the hole in the near cortex and push the screw through the hole and nail. C, Check the near cortexby pulling the cannula back to ensure that the screw is not inserted too far into the tibia.




Open Reduction for Closed FracturesIf closed reduction is not possible after a short time, a small

incision for open reduction can be made. This is made just over thefracture site on the anterolateral side. A periosteal elevator canalign the bone canals. It requires concentration and careful plan-

ning for the surgeon to use a small, appropriately placed openreduction incision. Palpate the fracture site and determine whetherthere is any overlapping of the fragments. In this situation, palpatethe distal end of the proximal fragment, place the incision at thissite and use a periosteal elevator to bluntly reflect muscle fiberslaterally and dissect down to the fracture site. Most trauma sur-geons recommend an anterior incision placed 1 to 2 cm lateral tothe crest of the tibia and pulling the anterior compartment muscleslaterally to expose the fracture site. Use of cutting electrocautery30

or a knife to cut through muscle is not recommended.After the end of one of the fracture fragments has been

identified, dissect the callus and scar circumferentially to allowmobilization of this fragment. Find the other bony fragment anddo likewise. Once these fragments have been freed enough toallow correction of the telescoping, the fracture may be reduced.Often these fracture fragments are still overlapped after beingfreed up. Place a bone clamp on both sides of the fracture site andallow the distal fragment to flex 90 degrees. Hook the posteriorcortex of both fragments and gradually extend the fragments at thefracture site. Care is sometimes required to wait for the tissues toslowly stretch out to length as the fracture site is extended.

FIGURE 18. The alignment pin is placed through the hex holein the head of the screw to align the target arm for placement ofa second distal interlocking screw.

FIGURE 19. Compress the fracture by attaching the extractorcompressor and weighted rod and backslapping the fracture. TheIM nail must be countersunk into the proximal tibia if backslap-ping is being considered to prevent prominence of the proximalnail and difficulties with kneeling.

FIGURE 20. Proximal locking screw insertion. The slot finder isnot necessary for proximal interlocking. Use the small drill bit (A).The holes are enlarged using the step drill (B).




Sometimes a periosteal elevator must be placed between thesefragments to stretch the tissues for the last 1 cm of length. Onepossible obstruction can be the eager assistant who attempts toapply traction without flexing at the fracture site.

Reduction must be maintained during reaming and inser-tion of the nail. A Loman or Verbrugge clamp is ideal for this.If the fracture is oblique, the ends can be approximated andpressure applied to slide the bones together. One surgeonshould be assigned the task of being sure reduction has beenmaintained. This is essential after the hole in the near cortex hasbeen drilled for placement of distal interlock. If the loss ofreduction goes unnoticed, the location of the slot in the nail willbe significantly delayed.

Proximal tibial fractures require care with respect to ap-propriate reduction and prevention of valgus and procurvatumdeformity. An open reduction may be required for a freshproximal tibial fracture if there is a tendency for the fracture tofall into either or both of these positions. Nork recommendsusing unicortical screw fixation and small fragment platesduring limited open reduction of the fracture. Once the fractureis anatomically aligned, the IM nailing can then proceed in amore controlled manner.31 Flexing the proximal fragment inrelation to the femur is very important. Some surgeons prefer toflex the proximal fragment using the Figure 4 position. Checkthe rotational alignment of the tibia once the tibial nail has beenfully seated.

SPECIAL CONSIDERATIONS

Open FracturesOpen fracture wounds must be continually evaluated by

the operating surgeon. The first step is to assess the damage tothe soft tissues, which often extends past the opening in theskin. Foreign bodies, dead muscle, dead bone, and soft tissuemust be removed. Copious irrigation continues as long asforeign material and dead tissue flow out of the wound.32 If thefracture is multifragmentary, small bony fragments withoutmuscle attachment are removed. Avoid soft-tissue stripping offracture fragments. High-pressure irrigation systems may forcebacteria back into the tissues and these bacteria will emergelater and cause infection. The location where the injury oc-curred may also add bacteria as in the classic “barnyard injury.”Appropriate antibiotics are given for these.

The most important decision the surgeon will make iswhether the wound can be loosely closed after debridement andthe nail inserted. If the wound is deemed clean enough to closewithout a great deal of dead space, the nail can be inserted. Placingexternal fixation for 10 days prior to nail insertion is used morefrequently in North America because of greater access to re-sources.33 Consider temporary external fixation for grossly con-taminated open fracture wounds or those patients requiring dam-age control orthopaedics. Early conversion to IM nail is best andcontra-indicated in patients with a recent pin-site infection orwound infection.34 The infection rate has been linked with the timethe external fixation has been in place, as well as the intervalbetween removal of the external fixator and placement of the IMnail with a delay of greater than 14 days offering an advantage interms of infection.33

Temporary external fixation is not as practical in devel-oping countries because of expense and operating room avail-ability. We are studying these decision trees on our database. Ifthe wound is clean and can be debrided and irrigated within 6to 12 hours of injury, nail fixation can be performed. Ifdefinitive wound closure is not recommended at the time of nail

fixation, bacteria that cause infection are introduced during thehospitalization. An important yet very simple method of pre-venting multiply-resistant nursing ward bacteria from enteringthe open fracture wound is to apply an antibiotic bead pouch.An antibiotic bead pouch can decrease the risk of hospital-acquired infection 4-fold35 and involves the use of an occlusiveplastic dressing. The wound remains moist and antibiotics leakfrom the beads into the serosanguinous fluid which is trappedby the occlusive dressing. The dressing is changed only in theoperating theater under strict aseptic technique (Fig. 21). Ifantibiotic beads are not available, simply wrapping the openfracture wound with an occlusive sterile clear plastic dressingwill also keep multiply drug-resistant ward bacteria from en-tering the wound. No gauze is used. Negative pressure woundtherapy can also be used.

Wound closure should be performed as early as possi-ble. If there is a great deal of muscle debridement andexposed bone, a muscle flap is usually required. The timingof the skin grafting of this muscle flap depends on surgicalexperience and availability of operating time. The earlier awound can be closed the better. Godina demonstrated amuch lower flap failure rate, lower infection rate, shorterhospitalization, fewer operative procedures, and much morerapid healing time for tibial fractures treated by microsur-gical reconstruction within 72 hours of injury.36 The flapfailure rate was 0.75% when performed earlier than 72 hoursfollowing injury but 12% when carried out at 3 days to 3months. After 3 to 4 days it becomes more difficult todiscern between the “zone of injury” and healthy recipientvessels. Recipient vessels lying within the zone of injuryhave activated platelets adherent to their intimal surfacesand the rate of postoperative anastomotic thrombosis ismuch higher. The infection rate for the early flap coverage

FIGURE 21. Antibiotic beads placed in a grossly contaminatedopen tibia fracture wound. Note the chain of antibiotics beadsbefore (A) and after (B) application of a sterile occlusive plasticdressing. Photo courtesy of Dr. David Templeman.




group was only 1.5% in Godina’s early coverage group (P �0.0005).

Significance: Definitive wound closure and stabiliza-tion of open fractures should be accomplished as soon aspossible after the initial debridement is completed.

Distal Tibial Metaphyseal FracturesDistal tibial metaphyseal fractures remain a significant

treatment challenge. Preoperative x-rays should be carefullyinspected to rule out intra-articular extension. Such extension isnot a contraindication to IM rod fixation but it is important toidentify an undisplaced fracture and place a peri-articular lagscrew across it before proceeding with rod fixation. There is nouniversal agreement with respect to distal fibular fixation. Somesurgeons prefer to fix the distal fibular fracture first using AOtechnique, lag screw fixation and neutralization plating.37 Theirrationale is that the tibial fracture then becomes a much moresimple and controlled IM nailing. When the distal fibula is fixedfirst, there is less concern about valgus alignment of the tibiabecause of fibular shortening and overlap.38 If the fibula isoverlapped, the ankle joint will be in valgus and plating of thefibula is recommended. The fibula may also be plated whenadditional stability is necessary. Another decision relates to theuse of the tibial IM rod to stabilize the fibula. This situationworks effectively for fibular fractures involving the proximaltwo-thirds. For distal tibial fractures, particularly in osteopo-rotic bone with a wide medullary canal, medial and lateralanteroposterior blocking screws provide additional stability tovarus-valgus displacement in the coronal plane. This is espe-cially important for distal tibial fractures where there is roomfor only 1 distal tibial interlocking screw.

Significance: Guidelines for stabilization of the fibulahave not yet been clearly defined.

Blocking (Poller) ScrewsWhen the fracture is in the proximal tibia, especially when

the fracture line extends higher on the posterior cortex, ablocking screw may be used.39,40 The blocking screw is placedfrom the medial side (Fig. 22). It is important to remember theanatomy of the peroneal nerve on the lateral side. After the drillhas been placed through both the medial and lateral cortex, usea hemostat and pass it through the entry point to determinewhether the drill has entered the reamed canal. If it has, placethe blocking screw more posteriorly. The blocking screw willguide the nail into the distal fragment but remember that itfunctionally narrows the tibial IM canal (Fig. 8). The blockingscrew can also be used for varus–valgus orientation of the nail.This is often used when the fracture is oblique in the medial–lateral plane. Remember the blocking screw is placed where thesurgeon does not want the nail to go. If the fracture is dia-grammed on a piece of paper before surgery, placement will beautomatic.

Significance: Remember that the blocking screwshould be placed on the concave side of the deformity thatis being noted in the operating theater.

FIGURE 22. Blocking screw insertion. Blocking screws are al-ways placed on the concave side of a deformity.

FIGURE 23. Distal tibial blocking screws placed on the concavelateral side prevent the distal tibia from falling into valgus. Re-printed with permission, Krettek C, J Bone Joint Surg, 1999.




For a varus procurvatum deformity of the distal tibia, theblocking screws will be placed medially and posteriorly (Fig. 23).In the distal tibia, the tibia medullary canal flares considerably andthe addition of blocking screws will also increase the strength andrigidity of the fixation. Also, when there is a butterfly fragment orabsence of cortex on 1 side of the distal tibia, the nail may wanderthrough this opening. A blocking screw can be more easily placedin the distal fragment because there is more room for the screw inthe flare of the tibial metaphysis (Fig. 23). Krettek’s initial expe-rience with 21 tibial fractures involved the management of 10proximal and 11 distal tibial fractures.39 All fractures healed at amean of 5.4 months. The mean alignment was 1 degree of valgus(range: 5 degrees valgus to 3 degrees varus) and mean procurva-tum 1.6 degrees (range: 6 degrees recurvatum to 11 degreesprocurvatum).

Segmental Bone LossFor most patients who have sustained segmental bone

loss, associated injury to the soft-tissue envelope will re-quire free flap coverage at the time of definitive woundclosure. Rotation flap coverage may sometimes be suitablefor smaller, more proximal defects or when the overallcondition of the patient is less favorable.41 If IM nailreconstruction is selected for management of a segmentaldefect, the amount of autologous cancellous bone graft thatwill be required should be carefully calculated.42 The pos-terior iliac crest provides up to 40 mL of cancellous au-tograft compared with 10 to 15 mL for the anterior crest.Using the bone from the flutes of the hand reamer can yielda significant quantity of bone suitable for butterfly defects orshort segmental defects during open reduction. If the defectexceeds the amount of available autograft, options include:allograft cancellous bone or transport over the IM nail.43– 45

Free vascularized fibula reconstruction and Ilizarov bonetransport in the absence of an IM nail are other treatmentoptions.46,47 The glycocalyx (biofilm) that forms arounddead bone and metal and harbors bacteria is different thanthe biologic membrane that forms around methylmethacry-late. Methylmethacrylate can be used as a spacer to maintaina pocket which will later be replaced with autogenouscancellous graft. When the methylmethacrylate spacer isremoved and bone graft inserted, bone formation is stimu-lated by the biologic membrane.14

Indications for Nail Removal and Anterior KneePain

The tibial IM nail may be removed48 once the fracture hasremodeled solidly, usually 18 to 24 months after fracture healing.In the experience of Court-Brown, knee pain resolved in27% and marked improvement was observed in 69% follow-ing tibial nail removal. Knee pain was worsened in 3% ofpatients.49 However, Buckley observed a 14% incidence ofworsening of knee pain with nail removal.50 No difference inknee pain has been observed for the tendon sparing approachversus transpatellar tendon approaches.17,18,51

CONCLUSION

Fractures of the tibia can be managed by SIGN IM nailinterlocking screw system in developing countries. The entrypoint is an important aspect of achieving accurate restoration ofalignment The fracture site should not be nailed in a distractedposition. If distraction is observed, back-slapping the nail will

improve bone apposition. If fluoroscopy is not used for theprocedure, and the fracture site is noted to be distracted onpostoperative x-rays, either revision surgery or early nail dy-namization should be considered. Definitive wound closure ofopen fracture wounds should be achieved as soon as possibleafter the initial debridement surgery usually by 3 to 7 days.Leave grossly contaminated wounds open and covered with anantibiotic bead pouch whether in doubt and perform repeatdebridement 24 to 36 hours later. Segmental bone loss can bemanaged most commonly by autogenous iliac crest bone graft-ing although more sophisticated techniques such as bone trans-port are occasionally required.

REFERENCES

1. Horn J, Schlegel U, Krettek C, et al. Infection resistance of unreamedsolid, hollow slotted and cannulated intramedullary nails: an in-vivoexperimental comparison. J Orthop Res 2005;23:810–815.

2. Arens S, Schlegel U, Printzen G, et al. Influence of materials forfixation implants on local infection: an experimental study of steelversus titanium DCP in rabbits. J Bone Joint Surg 1996;78-B:647–651.

3. Kraft CN, Diedrich O, Burian B, et al. Microvascular response ofstriated muscle to metal debris: a comparative in vivo study withtitanium and stainless steel. J Bone Joint Surg 2003;85:133–141.

4. Pieske O, Geleng P, Zaspel J, et al. Titanium alloy pins versus stainlesssteel pins in external fixation at the wrist: a randomized prospectivestudy. J Trauma 2008;64:1275–1280.

5. Soultanis KC, Pyrovolou N, Zahos KA, et al. Late postoperativeinfection following spinal instrumentation: stainless steel versus tita-nium implants. J Surg Orthop Adv 2008;17:193–199.

6. Shearer D, Zirkle LG Jr. Population characteristics and clinical out-comes from the SIGN online surgical database. Tech Orthop 2009;24:273–276.

7. Court-Brown CM, Christie J, McQueen MM. Closed intramedullarytibial nailing: its use in closed and type I open fractures. J Bone JointSurg 1990;72-B:605–611.

8. Court-Brown CM, McQueen MM, Quaba AA, et al. Locked intramed-ullary nailing of open tibial fractures. J Bone Joint Surg 1991;73-B:959–964.

9. Tanner J, Woodings D, Moncaster K. Preoperative hair removal toreduce surgical site infection. Cochrane Database Syst Rev 2006;3:CD004122.

10. Altpeter T, Luckhardt K, Lewis JN, et al. Expanded surgical time out:a key to real-time data collection and quality improvement. J Am CollSurg 2007;204:527–532.

11. Backster A, Teo A, Swift M, et al. Transforming the surgical “time-out”into a comprehensive “preparatory pause.” J Card Surg 2007;22:410–416.

12. Althausen PL, Neiman R, Finkemeier CG, et al. Incision placement forintramedullary tibial nailing: an anatomic study. J Orthop Trauma2002;16:687–690.

13. Schmidt AH, Templeman DC, Tornetta P, et al. Anatomic assessmentof the proper insertion site for a tibial intramedullary nail. J OrthopTrauma 2003;17:75–76.

14. Schmidt AH. Biologic membranes: good and bad. In: 8th AnnualSurgical Implant Generation Network (SIGN) Conference; August 14,2009; Richland, WA.

15. Weil YA, Gardner MJ, Boraiah S, et al. Anterior knee pain followinglateral parapatellar approach for tibial nailing. Arch Orthop TraumaSurg 2009;129:773–777.

16. Weninger P, Schultz A, Traxler H, et al. Anatomical assessment of theHoffa fat pad during insertion of a tibial inramedullary nail-comparisonof three surgical approaches. J Trauma 2009;66:1140–1145.




17. Toivanen JA, Vaisto O, Kannus P, et al. Anterior knee pain afterintramedullary nailing of fractures of the tibial shaft: a prospective,randomized study comparing two different nail-insertion techniques.J Bone Joint Surg Am 2002;84-A:580–585.

18. Vaisto O, Toivanen J, Kannus P, et al. Anterior knee pain afterintramedullary nailing of fractures of the tibial shaft: an eight-yearfollow-up of a prospective, randomized study comparing two differentnail-insertion techniques. J Trauma 2008;64:1511–1516.

19. Bhandari M, Guyatt G, Tornetta P III, et al. Randomized trial of reamedand unreamed intramedullary nailing of tibial shaft fractures (SPRINT).J Bone Joint Surg 2008;90-A:2567–2578.

20. Blachut PA, O’Brien PJ, Meek RN, et al. Interlocking intramedullarynailing with and without reaming for the treatment of closed fracturesof the tibial shaft: a prospective, randomized study. J Bone Joint Surg1997;79-A:640–646.

21. Govender S, Csimma C, Genant HK, et al. BMP-2 Evaluation inSurgery for Tibial Trauma (BESTT) Study Group. J Bone Joint Surg2002;84-A:2123–2134.

22. Keating JF, O’Brien PI, Blachut PA, et al. Reamed interlocking in-tramedullary nailing of open fractures of the tibia. Clin Orthop RelatRes 1997;338:182–191.

23. Venkateswaran B, Warner RM, Hunt N, et al. An easy and accuratepreoperative method for determining tibial nail lengths. Injury 2005;36:352.

24. Hupel TM, Weinberg JA, Aksenov SA, et al. Effect of unreamed, limitedreamed, and standard reamed intramedullary nailing on cortical boneporosity and new bone formation. J Orthop Trauma 2001;15:18–27.

25. Hajek PD, Bicknell HR Jr, Bronson WE, et al. The use of one comparedwith two distal screws in the treatment of femoral shaft fractures withinterlocking intramedullary nailing: a clinical and biomechanical anal-ysis. J Bone Joint Surg 1993;75-A:519–525.

26. Griffin LV, Harris RM, Zubak JJ. Fatigue strength of common tibialintramedullary nail distal locking screws. J Orthop Surg Res 2009;4:11.

27. Lang GJ, Richardson M, Bosse MJ, et al. Efficacy of surgical wounddrainage in orthopaedic trauma patients: a randomized prospective trial.J Orthop Trauma 1998;12:348–350.

28. Tieenk RM, Peeters MP, van den Ende E, et al. Wound drainage versusnon-drainage for proximal femoral fractures: a prospective randomizedstudy. Injury 2005;36:100–104.

29. Parker MJ, Livingstone V, Clifton R, et al. Closed suction surgicalwound drainage after orthopaedic surgery. Cochrane Database Syst Rev2007;18:CD001825.

30. Porter KA, O’Connor S, Rimm E, et al. Electrocautery as a factor inseroma formation following mastectomy. Am J Surg 1998;176:8–11.

31. Nork SE, Barei DP, Schildhauer TA, et al. Intramedullary nailing ofproximal quarter tibial fractures. J Orthop Trauma 2006;20:523–528.

32. Petrisor B, Jeray K, Schemitsch E, et al; FLOW Investigators. Fluidlavage in patients with open fracture wounds (FLOW): an internationalsurvey of 984 surgeons. BMC Musculoskelet Disord 2008;23;9:7.

33. Bhandari M, Zlowodzki M, Tornetta P III, et al. Intramedullary nailingfollowing external fixation in femoral and tibial fractures. J OrthopTrauma 2005;19:140–144.

34. Blachut PA, Meek RN, O’Brien PJ. External fixation and delayedintramedullary nailing of open fractures of the tibial shaft: a sequentialprotocol. J Bone Joint Surg 1990;72-A:729–735.

35. Keating JF, Blachut PA, O’Brien PJ, et al. Reamed nailing of opentibial fractures: does the antibiotic bead pouch reduce the deep infectionrate? J Orthop Trauma 1996;10:298–303.

36. Godina M. Early microsurgical reconstruction of complex trauma of theextremities. Plast Reconstr Surg 1986;76:719–728.

37. Egol KA, Weisz R, Hiebert R, et al. Does fibular plating improvealignment after intramedullary nailing of distal metaphyseal tibialfractures? J Orthop Trauma 2006;20:94–103.

38. Nork SE, Schwartz AK, Agel J, et al. Intramedullary nailing of distalmetaphyseal tibial fractures. J Bone Joint Surg Am 2005;87:1213–1221.

39. Krettek C, Stephan C, Schandelmaier P, et al. The use of Poller screwsas blocking screws in stabilising tibial fractures treated with smalldiameter intramedullary nails. J Bone Joint Surg 1999;81-B:963–968.

40. Krettek C, Miclau T, Schandelmaier P, et al. The mechanical effect ofblocking screws in stabilizing tibia fractures with short proximal ordistal fragments after insertion of small-diameter intramedullary. J Or-thop Trauma 1999;13:550–553.

41. Pollak AN, McCarthy ML, Burgess AR; The Lower Extremity Assess-ment Project (LEAP) Study Group. Short-term wound complicationsafter application of flaps for coverage of traumatic soft-tissue defectsabout the tibia. J Bone Joint Surg Am 2000;82-A:1681–1691.

42. Abdollahi K, Kumar PJ, Shepherd L, et al. Estimation of defect volumein segmental defects of the tibia and femur. J Trauma 1999;46:413–416.

43. Eralp L, Kocaoglu M. Distal tibial reconstruction with use of a circularexternal fixator and an intramedullary nail. Surgical technique. J BoneJoint Surg 2008;90-A(suppl 2 Pt 2):181–194.

44. Kocaoglu M, Eralp L, Rashid HU, et al. Reconstruction of segmentalbone defects due to chronic osteomyelitis with use of an external fixatorand intramedullary nail. J Bone Joint Surg 2006;88-A:2137–2145.

45. Oh CW, Song HR, Roh JY, et al. Bone transport over an intramedullarynail for reconstruction of long bone defects in tibia. Arch OrthopTrauma Surg 2008;28:801–808.

46. El Gammal TA, Shiha AE, El-Deen A, et al. Management of traumatictibial defects using free vascularized fibula or Ilizarov bone transport: acomparative study. Microsurgery 2008;28:339–346.

47. Rozbruch RS, Weitzman AM, Watson JT, et al. Simultaneous treatmentof tibial bone and soft-tissue defects with the Ilizarov method. J OrthopTrauma 2006;20:197–205.

48. Keating JF, Orfaly R, O’Brien PJ. Knee pain after tibial nailing.J Orthop Trauma 1997;11:10–13.

49. Court-Brown CM, Gustilo T, Shaw AD. Knee pain after intramedullarytibial nailing: its incidence, etiology, and outcome. J Orthop Trauma1997;11:103–105.

50. Sidky A, Buckley RE. Hardware removal after tibial fracture hashealed. Can J Surg 2008;51:263–268.

51. Court-Brown CM, Will E, Christie J, et al. Reamed or unreamed nailingfor closed tibial fractures: a prospective study in Tscherne C1 fractures.J Bone Joint Surg 1996;78-B:580–583.




use of interlocking intramedullary tibial nails in ... · pdf filereview article use of...

Documents